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When Algerian nationalists launched a rebellion against French rule in November 1954, France was forced to cope with a varied and adaptable Algerian strategy. In this volume, originally published in 1963, David Galula reconstructs the story of his highly successful command at the height of the rebellion. This groundbreaking work, with a new foreword by Bruce Hoffman, remains relevant to present-day counterinsurgency operations.

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Infectious Disease and National Security

Rand Corporation

Chapter One

Introduction

The emergence and spread of severe acute respiratory syndrome (SARS) in 2003 caused significant effects on the health, trade, and economies of a number of countries, particularly in Asia. Today, the world faces the potential threat of a human pandemic arising from avian influenza. While SARS did not cause significant mortality and morbidity within the United States, it served as yet another sobering lesson that emerging infectious diseases (EID) can have a significant effect on U.S. national security, with potential health, social, military, economic, and political effects. This lesson applies not only to newly emerging infectious diseases such as SARS, avian influenza H5N1, West Nile virus, and HIV/AIDS, but also to known diseases that have reemerged (such as tuberculosis and dengue fever), as well as emerging and reemerging animal (e.g., bovine spongiform encephalopathy ["mad cow disease"], foot-and-mouth disease) and plant (e.g., citrus canker) diseases.

The U.S. National Security Strategy of 2002 recognizes infectious diseases as a potential danger to the nation's security. However, it is not clear whether the links between infectious disease and national security are widely understood and how this new paradigm guides information collection and programming across government sectors. Current worldwidehealth information systems rely mostly on open and truthful reporting by governments. Such reporting does not always occur, either due to obfuscation (as appears to be partially the case with the SARS outbreak in China; see Chapter Three and Huang, 2003) or in part to the lack of a robust ability of some countries to detect and report human and animal disease within their own borders (e.g., HIV/AIDS in some African countries or avian influenza in some countries in southeast Asia).

Within the evolving new paradigm that links infectious disease to national security, what kind of information do government leaders need? Does the United States have a systematic approach to the collection of information for the early warning and tracking of infectious diseases originating outside U.S. borders? Is information collected by or available to the United States adequate for enabling a timely and effective response to protect national interests at home and abroad? These questions apply to a range of information collection sources that includes the more traditional health sector, the agriculture and foreign affairs sectors, and the intelligence community. How can the assets and approaches of these various sectors feed into coherent, integrated national information?

About This Study

Considering the need for good early warning information about infectious diseases that may affect U.S. national security or interests, the Advanced Systems and Concepts Office of the Defense Threat Reduction Agency asked the RAND Corporation to examine the evolving recognition of infectious disease as a national security threat and study how the United States collects, analyzes, and uses information about global infectious diseases. Data collection for this study was undertaken from July through October 2005, and analyses were completed in November 2005. The purpose of this study was to assess information priority needs concerning global infectious disease threats, and to determine the suitability of current information to support U.S. policy- and decisionmaking to prevent and respond to such threats. The research questions require careful consideration to help ensure that government leaders' information needs in this area are identified and met in the most efficient and effective manner possible.

The following questions guided this study:

How has the emerging link between global infectious disease and U.S. national security been perceived and acted upon across government sectors?

What types of information about global infectious diseases do U.S. policymakers need?

How sufficient is the available information on global infectious diseases?

Study Methods

We employed several methods to address the central study questions. Those methods included literature and document reviews, interviews with relevant stakeholders, and a survey of online infectious disease information sources.

Literature Review

We undertook a literature review to provide background information on infectious disease threats and impacts, responses to date, the evolution of connections between infectious disease and national security, and key U.S. and global policies and initiatives. The literature and document reviews covered peer-reviewed literature, government reports, congressional testimony, and reports by nongovernmental organizations. Media reports were consulted for timely information about specific events. In the climate of near-continuous changes in global infectious disease information reporting and U.S. homeland security efforts of the past several years, every effort was made to review the most recent documents, especially guidance from the U.S. government and international organizations. We principally reviewed documents less than ten years old, and we did not include documents published after August 2005, except where specifically noted. The results of our literature review are presented primarily in Chapters Two and Three.

Interviews with Stakeholders

To examine all three of our research questions, we conducted interviews with policymakers and staff at various levels of government and with nongovernmental, academic, and international experts. We sought input from a broad range of potential stakeholders, mostly within the federal government. We targeted senior policymakers or their staff in all cabinet departments with a potential interest in global infectious diseases, as well as their relevant agencies. We also sought the views of relevant stakeholders outside the federal government, including representatives from a state health department, the association for U.S. state health officers, and the World Health Organization. We developed a discussion guide for our semi-structured interviews. Our discussions were more focused in a few instances when more specific information was required: for example, details about specific infectious disease information systems or new government initiatives. We conducted our interviews between July and October 2005. The results of the interviews are presented at the end of Chapter Three and in Chapter Four.

Survey of Online Sources

To supplement the findings from our interviews and in assessing the adequacy of currently available information related to global infectious disease, we conducted a systematic search for and analysis of Internet-based information sources. Our early literature review suggested no evidence for a comprehensive, consolidated source of information on global infectious diseases, and our pilot interviews with selected government officials suggested that this would be useful to them. Therefore, we compiled and assessed online sources that contained information relevant primarily to the public health aspects of infectious diseases, most notably disease surveillance information. Our findings are presented in Chapter Five.

How This Report Is Organized

Chapter Two provides background information to frame the challenges of infectious diseases and highlight recent U.S. and global responses. Chapter Three addresses our first research question related to perceptions about infectious disease and national security. It provides specific historical background on how infectious disease is related to concepts of security, highlights key U.S. security-oriented responses, and presents findings from our interviews concerning current stakeholder perceptions about the connection between infectious disease and national security. Chapter Four addresses our second research question related to information needs, summarizing findings from stakeholder interviews, and Chapter Five addresses the third research question related to the adequacy of current information, focusing on the survey of online infectious disease information sources worldwide. Chapter Six presents our synthesis, conclusions, and recommendations.

Chapter Two

Background: Challenges of and Responses to Infectious Disease Threats

Response to infectious disease threats is a long-standing priority of health agencies in the United States and around the world. The link between infectious disease and national security is a relatively new concept. Understanding the challenges of infectious disease threats from this perspective provides a background from which to address our research questions about information needs and the adequacy of currently available information. The first section in this chapter highlights the toll and challenges of infectious diseases; the second section describes U.S. and global responses in recent years.

Infectious Disease Threats

The Toll of Infectious Diseases

Approximately a quarter of all deaths in the world today are due to infectious diseases. HIV/ AIDS, tuberculosis, malaria, pneumonia, and diarrheal diseases are the leading infectious disease causes of death and take a particularly large toll in developing countries (World Health Organization, 2004). In the United States, mortality due to infectious diseases decreased over the first eight decades of the 20th century and then increased between 1981 and 1995 (Armstrong, Conn, and Pinner, 1999). The average decline in infectious disease mortality rates accelerated from 2.8 percent per year from 1900 to 1937 to 8.2 percent per year between 1938 and 1952, then receded to an annual decline of 2.3 percent until 1980. Most experts attribute the declining mortality trends to improved water and sanitation and the introduction and widespread use of vaccines and antibiotics. From 1980 to 1992, the rate of deaths with an underlying infectious disease cause increased 58 percent (Pinner et al., 1996). Mortality increases in the more recent years were due to HIV/AIDS and, in the oldest age group, pneumonia and influenza.

The toll of infectious diseases over the past century can also be appreciated by comparing the leading causes of death at the beginning and end of the century (see Table 2.1). In 1900, four of the ten leading causes of death in this country were infectious diseases and collectively accounted for 31.9 percent of all deaths, including the top three (tuberculosis-11.3 percent of all deaths, pneumonia-10.2 percent, and diarrhea-8.1 percent) and the tenth (diphtheria-2.3 percent) (Cohen, 2000). In 2000, only pneumonia and influenza, which ranked seventh, 2.7 percent of all U.S. deaths, and a new infectious disease condition, septicemia (ranked tenth, 1.3 percent), were among the ten leading causes of death (National Center for Health Statistics, 2000).

Infectious Diseases in a Modernizing World

In comparison with the world before the end of the Cold War, borders are generally more open, and the pace of global travel, migration, and commerce has increased in recent decades. The effect of "globalization" on public health has been widely considered (for example, see Bettcher and Lee, 2002; Flanagan, Frost, and Kugler, 2001; Navarro, 1998; Roemer, 1998; and Yach and Bettcher, 1998a, 1998b). With globalization comes the benefits of increased commerce and closer international relationships, but globalization also presents new challenges and risks. One such challenge is that infectious diseases have followed a trend of increased global travel and spread. Just as infectious diseases are not confined to their nations of origin and have themselves become global in nature, appropriate responses to contain and control them have become a challenge to nations and require a global approach. This challenge has been addressed by the concept of global health, best described as "health threats and responses that, while inclusive of national governments, go beyond the action of nation-states" (Store, Welch, and Chen, 2003). While modern means of travel and migration have increased the threat of global disease spread by facilitating disease transmission among people and nations, modern times have also seen advances in the ability to recognize and treat infectious diseases.

Prior to the modern technologies that made rapid global travel possible, the geographic spread of infectious diseases was constrained by slower transportation: first, walking, then travel by animal, then ships and trains. The historic role of travelers (particularly armies, explorers, and merchants) and animals (e.g., rats carrying plague) in the introduction and spread of disease is well documented (for examples, see Berlinguer, 1992, and Wilson, 1995b, 2003b). However, slower transportation and communications during those times also reduced the potential for early warning and response to outbreaks. As ever-faster means of travel have facilitated the spread of infectious disease, modern communications technologies have also presented the opportunity for faster worldwide notification of disease outbreaks. Faster notification, in turn, presents the opportunity for quicker response to control outbreaks. A critical challenge is to harness the opportunities of modern communications to address the modern challenges of infectious diseases.

Today, people can traverse the globe in less time than it takes for many infectious agents to incubate and produce symptoms. For example, SARS emerged in rural China, spreading to Hong Kong and, from there, to 30 countries on six continents within several months-and this was a disease whose transmission rate pales in comparison with that of influenza (Osterholm, 2005). (SARS is discussed further in Chapter Three.) Compounding the problem is the fact that many pathogens can be transmitted by asymptomatic or mildly symptomatic persons, including travelers, who may be unaware that they are carriers (Wilder-Smith et al., 2002). Also disturbing are reports that pathogens carrying resistance genes can be transmitted from person to person, and among asymptomatic carriers (O'Brien, 2002), increasing the spread and prevalence of antimicrobial resistance. Mary Wilson summarizes the problem this way: "Current attributes of the world's population-including size, density, mobility, vulnerability, and location-have increased the risks for many infectious diseases, despite the availability of an unprecedented array of tools to prevent, diagnose, treat, and track them" (Wilson, 2003a).

New infectious diseases are emerging at an average rate of one per year (Woolhouse and Dye, 2001), and at least 30 new or newly recognized diseases have emerged in the last three decades (CISET, 1995; World Health Organization, 1996). Modern-day infectious disease risks are not limited to human-to-human contact. Approximately three-fourths of infectious diseases that have emerged and reemerged in recent decades are zoonoses, i.e., diseases transmitted to humans from animals (U.S. General Accounting Office, 2000b). Examples include HIV, West Nile virus, SARS, monkeypox, and several of the hemorrhagic fever viruses. Such exposures are characteristic of human encroachment into new habitats. Zoonotic diseases also can be introduced into a human population via agricultural trade, which is a critical element in many national economies worldwide.

A crowded, interconnected, and mobile world has presented new opportunities for pathogens to exploit their inherent abilities to rapidly multiply, mutate, evolve drug resistance and increased virulence, and find new (human) hosts (Heymann, 2003; Rodier, Ryan, and Heymann, 2000). Rapid and unplanned urbanization, particularly in developing countries, poses yet another set of risks for infectious disease transmission. Specific risk factors include poor sanitation, crowding, and sharing resources such as food and water (Moore, Gould, and Keary, 2003). As Heymann (2003) points out with numerous examples, the modernization of global trade and travel has resulted in the unprecedented emergence of new diseases, the reemergence of known diseases, and growing antimicrobial resistance.

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